Management of infertility

Delay in childbearing and the adverse effect of increasing age on women's fertility have increased referrals for fertility investigations and treatment. In the past 25 years the percentage of births to women age 30 and over in England and Wales has doubled (see fig A on bmj.com). 1 2 One in six couples require referral for investigation or treatment for subfertility.3 Couples are more aware of what can be done from media attention. Unfortunately, this often leads to falsely high expectations of fertility treatments. Natural human fertility is low compared with most other species. Peak human fertility (the chance of pregnancy per menstrual cycle in the most fertile couples) is no higher than 33%, and it is unrealistic to expect a higher chance of pregnancy than this from any fertility treatment. This review of the management of infertility, or more correctly subfertility, focuses on investigations (including over the counter fertility tests) and appropriate actions and treatments in response to test results. ### Summary points Natural human fertility is low, and most couples have falsely high hopes of fertility treatments The major causes of subfertility are sperm dysfunction, ovulation disorder, and fallopian tube damage Most investigations to establish a cause of subfertility are simple to undertake For most couples, history and examination will not indicate a cause, and full subfertility investigations will be needed Couples with sperm dysfunction or likely tubal damage should be referred early for specialist opinion Ovulation disorders often respond to simple treatments that can be safely initiated in primary care This article is based on 20 years' combined experience of running tertiary infertility clinics, together with the resources and regularly updated literature searches we have used over the past 14 years in preparation for annual postgraduate study days for primary care doctors. Within a year of regular intercourse, 90% …